Soft tissue repair device and associated methods

ABSTRACT

A fibrous tissue repair device includes first and second tubular anchors having corresponding longitudinal passages. The tissue repair device includes corresponding first and second inserters. Each inserter has a shaft with a distal portion received in the longitudinal passage of the corresponding tubular anchor. A flexible strand couples the first and second anchors.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No. 13/721,970 filed on Dec. 20, 2012, now U.S. Pat. No. 8,632,569, which is a divisional of U.S. patent application Ser. No. 13/045,689 filed on Mar. 11, 2011, now U.S. Pat. No. 8,337,525 issued on Dec. 25, 2012, which is a divisional of U.S. patent application Ser. No. 12/014,340 filed on Jan. 15, 2008, now U.S. Pat. No. 7,905,904 issued on Mar. 15, 2011, which claims the benefit of: (1.) U.S. Provisional Application No. 60/885,057, filed on Jan. 16, 2007, and (2.) U.S. Provisional Application No. 60/885,062, filed on Jan. 16, 2007, and which is a continuation-in-part of the following applications: (3.) U.S. patent application Ser. No. 11/347,661 filed on Feb. 3, 2006, now U.S. Pat. No. 7,749,250, issued on Jul. 6, 2010; (4.) U.S. patent application Ser. No. 11/935,681 filed on Nov. 6, 2007, now U.S. Pat. No. 7,905,903 issued on Mar. 15, 2011; (5.) U.S. patent application Ser. No. 11/869,440 filed on Oct. 9, 2007, now U.S. Pat. No. 7,857,830 issued on Dec. 28, 2010; which is a continuation-in-part of: (1.) U.S. patent application Ser. No. 11/408,282 filed on Apr. 20, 2006, now abandoned; and (2.) U.S. patent application Ser. No. 11/541,506 filed on Sep. 29, 2006, now U.S. Pat. No. 7,601,165 issued on Oct. 13, 2009.

The disclosures of the above applications are incorporated herein by reference.

INTRODUCTION

Tears caused by trauma or disease in fibrous soft tissue, such as cartilage, ligament, or muscle, can be repaired by suturing. Various repair devices have been developed for facilitating suturing and are effective for their intended purposes. Nevertheless, tissue repair devices for facilitating suturing are still desirable.

SUMMARY

The present teachings provide a fibrous tissue repair device that includes first and second tubular anchors having corresponding longitudinal passages. The tissue repair device includes corresponding first and second inserters. Each inserter has a shaft with a distal portion received in the longitudinal passage of the corresponding tubular anchor. A flexible strand couples the first and second anchors.

In some embodiments the anchors are non-deformable. In some embodiments, the tissue repair device includes a cannula having a handle and a passage receiving the first and second inserters.

In some embodiments, the fibrous repair device includes a handle, first and second inserters movable relative to the handle, and first and second anchors pre-loaded on corresponding external surfaces of the first and second inserters. The repair device also includes a control mechanism operable to control a deployment sequence of the first and second inserters for deploying the corresponding first and second anchors, such that the second inserter is prevented from deploying the second anchor until the first anchor is deployed by the first inserter.

In some embodiments, the fibrous tissue repair device includes a handle, a first inserter movable relative to the handle, a first anchor pre-loaded on an external surface of the first inserter, and a first slider coupled to the handle for moving the first inserter between deployment and retraction positions. The repair device can also include a second inserter movable relative to the handle, a second anchor pre-loaded on an external surface of the second inserter, and a second slider coupled to the handle for moving the second inserter between deployment and retraction positions. Further, the repair device can include a slider control mechanism coupled to the first and second sliders and operable to control a motion sequence of the first and second inserters, such that the first inserter is constrained to move to a deployment position before the second inserter. The repair device can also include a flexible strand coupling the first and second anchors. The flexible strand can pass through portions of the first and second anchors and form an adjustable knotless loop.

The present teachings also provide a method of repairing fibrous tissue. The method includes preloading a first anchor externally onto a first inserter, passing the first inserter from a first side to a second side of the fibrous tissue at a first location, delivering the first anchor on the second side of the fibrous tissue, and retracting the first inserter away from the tissue.

Further areas of applicability of the present invention will become apparent from the description provided hereinafter. It should be understood that the description and specific examples are intended for purposes of illustration only and are not intended to limit the scope of the invention.

BRIEF DESCRIPTION OF THE DRAWINGS

The present invention will become more fully understood from the detailed description and the accompanying drawings, wherein:

FIG. 1 is side view of a tissue repair device according to the present teachings;

FIG. 1A is a perspective view of a tissue repair kit according to the present teachings;

FIG. 2 is a perspective view of a tissue repair device according to the present teachings;

FIG. 3 is an enlarged perspective view of a tissue repair device according to the present teachings;

FIG. 4 is a side view of a tissue repair device according to the present teachings shown in a first position;

FIG. 5 is a side view of the device of FIG. 4 shown in a second position;

FIG. 6 is an enlarged side view of a tissue repair device according to the present teachings;

FIG. 7 is an enlarged side view of a tissue repair device according to the present teachings;

FIG. 8 is an enlarged side view of a tissue repair device according to the present teachings;

FIGS. 9A-C are perspective views of a flexible anchor shown with flexible strand arrangements according to the present teachings;

FIG. 9D is a perspective view illustrating a first configuration and a first orientation of an anchor relative to soft tissue according to the present teachings;

FIG. 9E is a perspective view illustrating a second configuration and a second orientation of the anchor of FIG. 9E relative to soft tissue according to the present teachings;

FIG. 10 is a perspective view of two pre-loaded inserters according to the present teachings;

FIG. 11 is an environmental view illustrating inserting a first anchor through soft tissue according to the present teachings;

FIG. 12 is an environmental view illustrating delivering a first anchor on an outer surface of soft tissue according to the present teachings;

FIG. 13 is a perspective view illustrating connecting a flexible strand between first and second anchors according to the present teachings;

FIG. 14 is an environmental view illustrating delivering a second anchor on an outer surface of soft tissue according to the present teachings;

FIG. 15 is a perspective view illustrating passing a free end of flexible strand connecting first and second anchors through a slip knot according to the present teachings;

FIG. 15A is a perspective view illustrating first and second anchors connected by a flexible strand according to the present teachings;

FIG. 15B is a perspective view of a soft tissue repair device according to the present teachings;

FIG. 16 is an environmental view illustrating a soft tissue defect repair with two anchors according to the present teachings;

FIG. 17 is side view of a tissue repair device according to the present teachings;

FIG. 18 is an enlarged side view of the device of FIG. 17;

FIG. 19 is an exploded view of FIG. 17;

FIG. 20 is a perspective view of an anchor according to the present teachings;

FIG. 21 is a perspective view of two pre-loaded inserters according to the present teachings;

FIG. 22 is a perspective view illustrating connecting a flexible strand between first and second anchors according to the present teachings;

FIG. 23 is a perspective view illustrating passing a free end of flexible strand connecting first and second anchors through a slip knot according to the present teachings;

FIG. 24 is a perspective view of two pre-loaded inserters according to the present teachings;

FIG. 25 is a perspective view illustrating connecting a flexible strand between first and second anchors according to the present teachings;

FIG. 26 is a perspective view illustrating passing a free end of flexible strand connecting first and second anchors through a slip knot according to the present teachings;

FIG. 26A is a perspective view illustrating first and second anchors connected by a flexible strand according to the present teachings;

FIG. 26B is a perspective view of a soft tissue repair device according to the present teachings;

FIG. 27 is an environmental view illustrating delivering a second anchor on an outer surface of soft tissue according to the present teachings;

FIGS. 28A and 28B are environmental views illustrating a soft tissue defect repair with two anchors according to the present teachings;

FIG. 29 is partially exploded perspective view of an inserter assembly according to the present teachings;

FIG. 30 is a plan view of the inserter assembly of FIG. 29;

FIG. 31 is another partially exploded view of the inserter assembly of FIG. 29;

FIG. 32 is a detail of a partially exploded view of the inserter assembly of FIG. 29;

FIGS. 33, 34, 35 and 36 are sequential views illustrating an exemplary method of coupling first and second flexible anchors with a flexible strand, and FIG. 35A shows a detail of FIG. 35;

FIG. 37 is a view illustrating loading first and second flexible anchors on the inserter assembly of FIG. 29;

FIG. 38 is a perspective view of a flexible anchor coupled with a flexible strand;

FIG. 39A is a bottom view of an anchor according to the present teachings;

FIG. 39B is a top view of the anchor of FIG. 39A;

FIG. 40 is a view illustrating coupling first and second anchors with a flexible strand according to the present teachings; and

FIG. 41 is a perspective view showing an anchor loaded onto an inserter according to the present teachings.

DESCRIPTION OF VARIOUS ASPECTS

The following description is merely exemplary in nature and is in no way intended to limit the invention, its application, or uses. For example, although the present teachings are illustrated in an application for meniscus repair in knee surgery, the present teachings can also be used for repairing any fibrous tissue, such as muscle, ligament or tendon in an arthroscopic or other open procedure, including rotator cuff reconstruction, acromioclavicular (AC) reconstruction, anterior cruciate ligament reconstruction (ACL) and generally for fastening tendons, grafts, or strands to fibrous tissue and bone. Additionally, the present teachings can be used for repairing tissue in cardiological, laparoscopic, urological, plastic or other procedures.

An exemplary tissue repair device 100 according to the present teachings is illustrated in FIG. 1, and in a kit form in FIG. 1A. The device 100 can include one or more inserters 102 and a cannula 200. The inserters 102 can be single-use, disposable, or sterilizable inserters. Each inserter 102 can be externally pre-loaded on its outer or external surface 121 with a single flexible anchor 150, as described below. The inserter 102 can include a handle 104 and a solid shaft 106 having a solid distal portion 108.

Referring to FIGS. 6-8, the distal portion 108 can include a sharp edge 110 defined by an inclined surface 112. The distal portion 108 can also include an external groove or slot 120 which is formed in a direction that is transverse or substantially perpendicular to the shaft 106. The distal portion 108 can also include two opposing substantially planar surfaces 116 defining a buttress 118. It will be appreciated that the outer or external surface 121 of the distal portion 108 incorporates the external groove 120, the planar surfaces 116 and the buttress 118.

The flexible anchor 150 can be an elongated member having first and second ends 152, 154. The flexible anchor 150 can be made of resorbable or non-resorbable materials, including braided suture, sponges and sponge-like materials in solid form, perforated materials, woven/braided from biocompatible materials or fibers, such as, for example, polymer, polyester, polyethylene, cotton, silk, or other natural or synthetic materials, including sponges and sponge-like materials. The flexible anchor 150 can also be an elongated tubular or solid member or a two-dimensional member with or without internal bores. The flexible anchor 150 can have any properties that allow the flexible anchor 150 to change shape. The flexible anchor 150 can be, for example, compliant, flexible, foldable, squashable, squeezable, deformable, limp, flaccid, elastic, low-modulus, soft, spongy, perforated or any other flexible member which can change shape. In some aspects, the flexible anchor 150 can be coated with biological or biocompatible coatings, and it can also be soaked in platelets and other biologics, which can be easily absorbed by the flexible anchor 150 in particular when, for example, the flexible anchor 150 is made from spongy, absorbent material.

It should be understood by the above description that the flexible anchor 150 cannot pierce or otherwise penetrate tissue either with the first and second ends 152, 154 or with any portion thereof. The flexible anchor 150 can be loaded solely on the external surface 121 of the distal portion 108 of the shaft 106 in a folded configuration, such at the first and second ends 152, 154 are facing each other. Accordingly, no portion of the anchor 150 is received even partially in or within the inserter, in contrast to prior art hollow needles and tubes that define an interior tubular surface within which one or more anchors are held substantially in their entirety. More specifically, an intermediate portion 156 of the flexible anchor 150 can be smoothly bent in a substantially U-shape, and draped over the external groove 120, while the first and second ends 152, 154 extend along the flat portions 116 of the shaft 106 of the inserter 102. The flexible anchor 150 can be in the form of an elongate flexible tube defining a bore 158 along its length, as shown in FIG. 9A. The flexible anchor 150 can be formed of suture braided without a core.

Referring to FIGS. 1, 1A, and 6-8, the cannula 200 can include a handle 202 and a tubular or hollow shaft 204. The shaft 204 of the cannula 200 can have a longitudinal bore 220 having an inner diameter sized to receive the shaft 106 of the inserter 102. The shaft 204 of the cannula 200 can have a distal end 206 which can be perpendicular relative to the shaft 204, although it can be also be slanted relative to the shaft 204 as shown in phantom line in FIG. 6. The distal end 206 of the cannula 200 has a rounded, blunt or smooth edge, which is not intended to or capable of piercing or otherwise penetrating tissue, whether the distal end 206 is slanted or perpendicular to the shaft 204.

Referring to FIG. 8, the cannula shaft 204 can include a cut-away slot 208 defining a viewing window 210. The window 210 can be covered with clear plastic, for example in the form of a tubular member 212 received in the bore 220 of the cannula shaft 204.

Referring to FIGS. 4 and 5, the soft tissue repair device 100 can be used with a depth limiter 500. The depth limiter 500 can be installed over the shaft 106 of the inserter 102 and between the handle 104 of the inserter 102 and the handle 204 of the cannula 200. The depth limiter can operate as an actuator using, for example, a rack-and-gear mechanism to move the shaft 106 of the inserter 102 relative to the shaft 204 of the cannula 200 between the position shown in FIG. 4, and the position shown in FIG. 5. In the position of FIG. 4, the inserter 102 extends a distance “D” beyond the distal end 206 of the cannula 200. In the position of FIG. 5, the inserter 102 extends a distance “D-d” beyond the distal end 206 of the cannula 200, where “d” is a retraction distance of the depth limiter 500. Alternatively, a separate disposable depth limiter in the form of a plastic tube 200′ that can be cut to a desired depth by removing a portion of length “d” can also be used over the shaft 106 of the inserter 102, as shown in FIG. 1A. The cannula 200, on the other hand, can be reusable.

Referring to FIGS. 1A and 9A-9C, the flexible anchor 150 can be assembled bent in a U-shape form on the inserter 102 with a continuous strand loop 300 attached thereon. The strand loop 300 can be formed by a single segment of flexible strand 301 passing through the bore 158 of the anchor 150, such that the strand loop 300 includes a first external segment or portion 302 outside the bore 158 and between the ends 152, 154, and a second external segment portion 304 located outside the bore 158 and exiting the bore 158 from exit positions or openings 160, 162 on opposite sides of the bent U-shape of the flexible anchor 150. The flexible strand 301 can be made of braided filaments or fibers of biocompatible material, including natural and synthetic fibers, such as cotton, silk, polymer, polyester, polyethylene, thin wire, suture, and other materials.

The strand loop 300 can be formed by tying the ends of the segment with a knot 306 which can be positioned on either the first external portion 302 or the second external portion 304, as shown in FIGS. 9B and 9C respectively. It will be appreciated that the loop 300 can define first and second secondary loops or sub-loops 310, 312. The first sub-loop 310 can include the first external portion 302, and the second sub-loop can include the second external portion 304. The first and second sub-loops 310, 312 can intersect each other, and each sub-loop 310, 312 can pass through the bent portion of the bore 158 corresponding to the intermediate portion 156 of the flexible anchor 150.

Referring to FIGS. 10-15, the soft tissue repair device 100 can be used to repair a soft tissue defect 90, such as, for example, a tear, or other weakness in fibrous soft tissue 80, such as in meniscal tissue, cartilage, muscle or other fibrous tissue under the skin. After an outer incision is made through the skin to access the soft tissue 80, the cannula 200 can be positioned through the incision without cutting or piercing any tissue and placed adjacent the soft tissue 80, such as fibrous meniscal tissue, and operate as an access portal for the inserter 102, as shown in FIG. 11. In the following exemplary procedure, the kit of FIG. 1A that includes first and second inserters 102 can be used with the cannula 200 to repair the soft tissue 80. The first and second inserters 102 and their respective features, although identical, will be distinguished for descriptive clarity by appending the letters “a” and “b”, e.g. inserters 102 a, 102 b, shafts 106 a, 106 b, etc., when desirable for further clarity. Similarly, the associated anchors 150 and their features, as well as other devices used in the procedure will also be distinguished, by appending the letters “a” and “b”, when desirable for further descriptive clarity.

Referring to FIG. 10, the first inserter 102 a can be assembled with the first anchor 150 a externally coupled thereon, as shown. A first flexible strand 350 a having a first “free” end 352 and a second end 354 can be coupled on a first threader 400 a with a slip knot 356. The first strand 350 a can pass through the first strand loop 300 a at the second external portion 304 a. The second inserter 102 b can be assembled with the second anchor 150 b externally coupled thereon, as shown. A second strand 350 b coupled to a second threader 400 b can pass through the second strand loop 300 b at the second external portion 304 b of the second anchor 150 b. Accordingly, the first and second inserters 102 a, 102 b can be independently pre-assembled, such that the first and second anchors 150 a, 150 b are only connectable to each other intra-operatively.

Referring to FIGS. 11-14, in an exemplary meniscal repair of a knee joint, the cannula 200 can be passed through the incision into the knee joint without piercing any fibrous tissue, except the tissue of the knee joint capsule, and positioned adjacent the meniscus. The first inserter 102 a can be passed through the cannula 200 and into the soft tissue 80 or meniscus from a first side of the defect 90 until the shaft 106 a of the first inserter 102 a can exit a second side 82 of the soft tissue 80, such as an outer surface or back side of the meniscus of the knee joint or other outer surface of a fibrous tissue, for example. The shaft 106 a of the first inserter 102 a can be sufficiently pushed through the second side 82 of the soft tissue 80 such that upon retraction of the first shaft 106 a, the first anchor 150 a can be pulled off the first shaft 106 a by the spontaneously closing tissue and remain on the second side 82 of the soft tissue 80 at a first location, as shown in FIG. 12. The first inserter 102 a can then be removed and discarded.

It will be appreciated that the manner and structure of the pre-assembled inserter 102 and anchor 150 allows the anchor 150 to pass through a narrow opening or slit formed in the tissue 80 by the edge 110 of the inserter 102 in a first low-profile folded configuration defining a plane “A”, as shown in FIG. 9D, and deposited in that configuration outside the tissue 80. It will be appreciated that the flexible anchor 150 is deployed in its U-shape configuration with the first and second ends 152, 154 being delivered substantially simultaneously. Further, it will be understood that tightening the first strand loop 300 by pulling on the second external portion 304 can cause the anchor 150 to deform to a second configuration having a substantially flat round-like or knurled shape. Further pulling on the second external portion 304 can rotate the first anchor 150 a from a first orientation defined by plane A and substantially perpendicular to the outer surface 82 to a second orientation such that the deformed anchor 150 can define a plane “B” substantially parallel to and lying on the outer surface 82 of the soft tissue 80 in a substantially flat shape, as shown in FIG. 9E.

Referring to FIGS. 13 and 14, the first strand 350 a can be captured by the second threader 400 and passed through the second external portion 304 b of the second strand loop 300 b of the second anchor 150 b, which is pre-loaded on the second inserter 102 b, as shown in FIG. 13. The second inserter 102 b can be inserted through the cannula 200 which is positioned adjacent but without piercing the fibrous tissue as described above, and the second anchor 150 b can be delivered to the second side 82 of the soft tissue 80 at a second location, as shown in FIG. 14. The second inserter 102 b can then be removed and discarded.

Referring to FIG. 15, the first strand 350 a can be captured by the first threader 400 a, and the free end 352 can be passed through the slip knot 356. The free end 352 of the first strand 350 a can be tensioned, thereby deforming each of the anchors 150 a, 150 b to a substantially flat round-like or knurled shape that can lie substantially flat on the second side 82 of the soft tissue, and compressing the defect 90. Any excess portion of the first strand 350 a can be cut off, as shown in FIG. 16. It will be appreciated that more than two anchors 150 can be deployed using a corresponding number of inserters 102. The additional anchors 150 can be connected with the first strand 350 a after the second anchor 150 b is deployed in the manner described above. Alternatively, additional anchors 150 can be connected independently of the first and second anchors 150 a, 150 b, either in pairs or singly.

Referring to FIGS. 15A and 15B, the flexible strand 350 can be pre-loaded on the first and second anchors 150, 150 b, with the free end 352 passing through the slip knot 356, as shown. The first and second anchors 150 a, 150 b can be deployed as described above using the first and second inserters 102 a, 102 b with the interconnected anchors 150 a, 150 b assembled thereon. The bore 220 of the hollow shaft 204 of the cannula 200 can have an elongated shape, or an eight-like shape shown in phantom lines in FIG. 15A, for receiving both the first and second inserters 102 a, 102 b sequentially or simultaneously. The handles 104 a, 104 b of the first and second inserters 102 a, 102 b can have corresponding flat surfaces 105 a, 105 b, facing one another and slidable relative to one another, such that each of the first and second inserters 102 a, 102 b can be independently inserted into or retracted from the cannula bore 220 without interference or obstruction from the other.

Alternative loop arrangements for coupling and deforming flexible anchors 150 a, 150 b are discussed below in reference with FIGS. 33-38.

Referring to FIGS. 17-26, a similar procedure can be used to repair a defect 90 in soft tissue 80 using a non-deformable or substantially rigid anchor 600. The anchor 600 can be made of any biocompatible material, such as, for example, titanium or other non-resorbable or resorbable material, including polymeric materials and Lactosorb® commercially available from Biomet, Inc., Warsaw, Ind. Referring to FIG. 20, the anchor 600 can be tubular defining a longitudinal bore 602 that extends between first and second ends 604, 606 of the anchor 600. The longitudinal bore 602 can be substantially D-shaped. The ends 604, 606 of the anchor 600 have blunt rounded edges substantially perpendicular to the anchor 600, such that the ends 604, 606 are not capable and not intended for piercing or penetrating tissue. The anchor 600 can further define a transverse bore 610 oriented at an angle to the longitudinal bore 602, such as, for example, 90-degrees or other suitable angle relative to the longitudinal bore 602. A flexible strand loop 620 can be passed through the transverse bore 610.

Alternative non-deformable anchors and loop arrangements are discussed below in reference with FIGS. 39A-41.

Referring to FIG. 17-19, the anchor 600 can be inserted in tissue using an inserter 650 similar to the inserter 102 shown in FIG. 1A, but configured to be coupled with the anchor 600. The inserter 650 can be used with the cannula 200, as described above. The inserter 650 can include a handle 652, and a solid shaft 654 having a solid distal portion 656. The distal portion 656 can terminate at a sharp edge 658 defined by a slanted surface 660. The distal portion 656 can include a buttress or stop 668 on which the second end 606 of the anchor 600 can abut, as shown in FIG. 18. The distal portion 656 that extends between the slanted surface 660 and the buttress 668 can have a D-shaped cross-section configured to be received in the D-shaped longitudinal bore 602 of the anchor 600 in a keyed manner that does not permit relative rotation between the anchor 600 and the shaft 654.

The inserter 650 and anchor 600 can be used for fibrous tissue repair as described above in reference to FIGS. 10-16. In one exemplary procedure, illustrated in FIGS. 21-23, first and second disposable inserters 650 a and 650 b independently pre-assembled with first and second anchors 600 a, 600 b, respectively, can be used. Each anchor 600 a, 600 b can include a corresponding strand loop 670 a, 670 b passing through each transverse bore 610 a, 610 b. A first flexible strand 680 having a first or free end 682 and a second end 684 can be passed through the first strand loop 670 a and coupled with a slip knot 686 to a first threader 400 a. Similarly, a second flexible strand 680 b coupled to a second threader 400 b can pass through the second strand loop 670 b.

The first inserter 650 a can be passed through the cannula 200 into the soft tissue 80 from a first side of the defect 90 until the shaft 654 a of the first inserter 650 a can exit the second side 82 of the fibrous soft tissue 80, such that upon retraction of the first shaft 654 a, the first anchor 650 a can be pulled off the first shaft 654 a by the closing tissue and remain on the second side 82 of the soft tissue 80 at a first location, as shown in FIG. 27. The first inserter 650 a can then be removed and discarded.

The first strand 680 a can be captured intra-operatively by the second threader 400 b and passed through the second strand loop 670 b of the second anchor 600 b which is pre-loaded on the second inserter 650 b, as shown in FIG. 22. The second inserter 650 b can be inserted through the cannula 200 and the second anchor 600 b can be delivered to the second side 82 of the soft tissue 80 at a second location, as shown in FIG. 27. The second inserter 650 b can be removed and discarded.

Referring to FIG. 23, the first strand 680 a can be captured by the first threader 400 a and the free end 682 can be passed through the slip knot 686. The free end 682 of the first strand 680 a can be tensioned, thereby rotating the anchors 600 a, 600 b such that each anchor 60 a, 600 b is positioned with its longitudinal axis parallel to the surface of the second side 82 of the soft tissue 80. Tensioning the first strand 680 a further can compress the defect 90. Any excess portion of the first strand 680 a can be cut off, as shown in FIG. 27.

Referring to FIGS. 24-26, an alternative intra-operative strand connection for the first and second anchors 600 a, 600 b is illustrated in which strand loops such as loops 670 a, 670 b shown in FIGS. 21-23 are not used. Rather, the first inserter 650 a can be assembled with the first strand 680 a passing through the transverse bore 610 a of the first anchor 600 a and coupled to the first threader 600 a, as shown in FIG. 24. Similarly, the second inserter 650 b can be also assembled with the second strand 680 b passing through the transverse bore 610 b of the second anchor 600 b and coupled to the second threader 400 b. After the first anchor 600 a is implanted on the second side 82 of the soft tissue 80 and the first inserter 650 a is removed and discarded, the first strand 680 a can be pulled by the second threader 400 b through the transverse bore 610 b of the second anchor 600 b, as shown in FIG. 25. After the second anchor 600 b is also implanted and the second inserter 650 b removed and discarded, the free end 682 of the first strand 680 a can be captured by the first threader 400 a and passed through the slip knot 686, as shown in FIG. 26. The first strand 680 is then tensioned to reduce the defect 90, as described above and shown in FIGS. 28A and 28B.

Referring to FIGS. 26A and 26B, the flexible strand 680 can be pre-loaded on the first and second anchors 600 a, 600 b with the free end 682 passing through the slip knot 686, as shown. The first and second anchors 600 a, 600 b, can be deployed as described above using the first and second inserters 650 a, 650 b with the interconnected anchors 600 a, 600 b assembled thereon. The bore 220 of the hollow shaft 204 of the cannula 200 can have an elongated shape, or an eight-like shape as described in connection with FIG. 15B above. The cannula 200 can be used for receiving both the first and second inserters 650 a, 650 b sequentially or simultaneously, as shown in FIG. 26B. The handles 652 a, 652 b of the first and second inserters 650 a, 650 b can have corresponding flat surfaces 655 a, 655 b, facing one another and slidable relative to one another, such that each of the first and second inserters 650 a, 650 b can be independently inserted into or retracted from the cannula bore 220 without interference or obstruction from the other.

Referring to FIGS. 29-32 and 37, various views of an inserter assembly 800 carrying first and second inserters 102 a, 102 b, such as those described above, are illustrated. The inserter assembly 800 can be optionally used with a cannula. The inserter assembly 800 can include a handle 802 and first and second sliders 804 a, 804 b operable for selectively and separately moving the corresponding inserters 102 a, 102 b, as described below. The handle 802 can be constructed from first and second handle portions 802 a, 802 b that are bonded or otherwise attached to one another.

In one aspect, the inserter assembly 800 can also include a slider control mechanism 806 between the first and second handle portions 802 a, 802 b. The slider control mechanism 806 can be coupled to the first and second sliders 804 a, 805 b and is operable to prioritize the separate deployment of the first and second flexible anchors 150 a, 150 b, which are loaded on the respective first and second inserters 102 a, 102 b. The slider control mechanism 806 can include a pivotable disc 808 having first and second posts or pins 810 a, 810 b on a first side and a third post or pin 812 on a second side opposite the first side, as shown in FIGS. 29, 31, and 32. The first and second posts 810 a, 810 b can move along respective first and second curved tracks 814 a, 814 b, respectively associated with the first and second sliders 804 a, 804 b. The third post 812 can move along an associated third curved track or groove 816 defined on an inner surface of the second handle portion 802 b.

In one aspect, by the cooperation of the first and second tracks 804 a, 804 b, and the disc 808, the slider control mechanism 806 can enable a forward or deployment motion of the first inserter 102 a, before enabling a retraction motion of the first inserter 102 a and a subsequent forward or deployment motion of the second inserter 102 b. The preferential deployment of the first inserter 102 a ensures that the first anchor 150 a will be deployed before the second anchor 150 b, although the first and second flexible anchors 150 a, 150 b are substantially identical. The second anchor 150 b is the anchor associated with the adjustment portion 908 and from which the free second end 904 of the flexible strand 900 exits. As discussed above, each anchor 150 a, 150 b can be sleeve-like having first and second ends 152, 154 and a longitudinal bore 158 extending between the first and second ends 152, 154. See also FIG. 38.

Referring to FIGS. 33-38, another aspect of coupling the flexible anchors 150 a, 150 b with a flexible strand 900 is illustrated. The flexible strand 900 can have first and second ends 902, 904 and can be made of materials similar to those discussed above in reference to the flexible strand 301. The flexible strand 900 can be braided in a tubular or hollow form such that it forms an internal passage 901 along the first and second ends 902, 904. A small knot or other retaining device 906 can be optionally formed adjacent the first end 902. It will be appreciated that the knot 906 can be entirely omitted. The flexible strand 900 can be passed through a first opening 160 of each flexible anchor 150 a, 150 b, guided along the bore 158 and exit through a second opening 162 of each flexible anchor 150 a, 150 b, as shown in FIG. 34. The openings 160, 162 can be positioned between the first and second ends 152, 154 of each flexible anchor 150 a, 150 b, at a distance of, for example one-quarter length from the ends 152, 154. Furthermore, it will be appreciated that the openings 160, 162 can be voids in the woven fabric of the flexible anchors 150 a, 150 b, such that the openings 160, 162 do not disrupt or break the weave of flexible anchors 150 a, 150 b, when the flexible anchors 150 a, 150 b are made of braided or woven material.

After the flexible anchors 150 a, 150 b are mounted on the flexible strand 900, the second end 904 of the flexible strand 900 can be passed into the internal passage 901 of the flexible strand 900 at an aperture 903, guided longitudinally along the passage 901, and guided out of the flexible strand 900 at an aperture 905. The portion of the flexible strand 900 between apertures 901 and 905 can form an adjustment portion 908 between the knot 906 and the opening 162 of the second flexible anchor 150 b, such that the flexible strand 900 defines a single adjustable knotless loop 910, as shown in FIGS. 35 and 35A. The second flexible anchor 150 b can be slidably moved along the flexible strand 900 until the adjustment position 908 is within the bore 158 of the second flexible anchor 150 b and the knot 906 is adjacent the opening 160 second flexible anchor 150 b, as shown in FIG. 36. It will be appreciated, however, that the adjustment portion 908 can remain in the position shown in FIG. 35. The adjustable knotless loop 910 is self-locking and does not require the surgeon to tie a knot during the surgical procedure for securing the flexible strand 900. Further, once the adjustable knotless loop 910 is self-locked by pulling the second end 904 of the flexible strand 900 and tensioning the flexible strand 900, friction prevents the adjustable knotless loop 910 from being loosened, thereby providing a secure lock. Additional details regarding forming the knotless adjustable loop 910 and other adjustable knotless loop configurations are disclosed in co-pending and commonly assigned U.S. patent application Ser. No. 11/541,506, filed on Sep. 29, 2006, the disclosure of which is incorporated herein by reference.

The first flexible anchor 150 a can be loaded on the first inserter 102 a, and second flexible anchor 150 b can be loaded on the second inserter 102 b, as shown in FIG. 37. The first and second anchors 150 a, 150 b can be loaded externally on their respective inserters in the manner discussed in reference with FIG. 13, above. Specifically, each of the first and second flexible anchors 150 a, 150 b can be draped over the external groove 120 in the distal portion of the corresponding inserter 102 a, 102 b. The inserter assembly 800 can be loaded with the first and second flexible anchors 150 a, 150 b coupled with the flexible strand 900, which forms the closed adjustable knotless loop 910. The adjustable knotless loop 910 allows tightening the strand 900, deforming the first and second flexible anchors 150 a, 150 b for anchoring and shortening the length of the adjustable knotless loop 910 without using a slipknot. The inserter assembly 800 can be used for repairing soft tissue 80, such as a meniscus tear 90, in a similar manner as discussed with reference to FIG. 14. The first slider 804 a can be moved forward to deploy the first flexible anchor 150 a at an outer surface 82 of the soft tissue. The first slider 804 a can then be moved backward, enabling the second slider 804 b to be moved forward to deploy the second flexible anchor 150 b at the outer surface 82 of the soft tissue, and adjacent the first flexible anchor 150 a. Pulling the second end 904 of the flexible strand 900 tightens the adjustable knotless loop 910, secures the first and second flexible anchors 150 a, 150 b against the outer surface 82 of the soft tissue 80 and reduces the defect 90. Further, the portions of the sleeve between the first and second ends 152, 154 of each of the flexible anchors 150 a, 150 b and the corresponding first and second openings 160, 162, define anchoring leg portions that provide additional resistance for securing the flexible anchors 150 a, 150 b on the outer surface 82 of the soft tissue 80, as these leg portions are forced against the outer surface 82 for anchoring.

Referring to FIGS. 39A-41, another non-deformable or substantially rigid anchor 1000 is illustrated. Similarly to the anchor 600 illustrated in FIG. 20, the anchor 1000 can be made of any biocompatible material, such as, for example, titanium or other non-resorbable or resorbable material, including polymeric materials and Lactosorb® commercially available from Biomet, Inc., Warsaw, Ind., and can be used in a similar manner to repair a soft tissue defect 90. The anchor 1000 can be tubular defining a longitudinal bore 1002 that extends between first and second ends 1004, 1006 of the anchor 600 and has an open, channel-like cross-section defining an arc of 180 degrees or more. The ends 1004, 1006 of the anchor 1000 have blunt rounded edges substantially perpendicular to the anchor 1000, such that the ends 1004, 1006 are not capable and not intended for piercing or penetrating tissue. The anchor 1000 can further define first and second transverse through bores 1010 oriented substantially perpendicularly to the anchor 1000. A flexible strand 900 can be passed through the transverse bores 1010 and couple first and second anchors 1000 a, 1000 b, as shown in FIG. 40. The strand 900 can be tightened with an adjustable knotless loop 910 by pulling on free end 904 and without the use of slipknot, as discussed above.

The first and second anchors 1000 a, 1000 b, coupled with the flexible strand 900, can be mounted on two separate inserters, as described above in connection with anchors 600. An exemplary inserter 1050 loaded with the anchor 1000 a is shown in FIG. 41. Two such inserters 1050 can be used with the inserter assembly 800 of FIG. 29, replacing the inserters 102 a, 102 b. Each inserter 1050 can have a cylindrical body 1052, a pointed tip 1054, and a stop 1056. The first anchor 1000 a can be mounted externally onto the body 1052 of the inserter 1050 between the tip 1054 and the stop 1056, such that that a portion of the inserter 1050 is received in the longitudinal bore 1002 of the first anchor 1000 a. The second anchor 1000 b can be similarly mounted on another inserter 1050. Each anchor 1000 a and 1000 b can be optionally mounted in a keyed manner onto the corresponding inserter 1050, such that accidental relative rotation is substantially prevented.

It will be appreciated from the above description and drawings that the present teachings provide anchors of versatile configurations that can be passed through fibrous tissue easily in a compact or low profile configuration and or orientation and then positioned outside the fibrous tissue in a second orientation that provides anchoring without tissue penetration, prevents withdrawal from the tissue and reduces tissue injury. Additionally, the inserter of the present teachings does not require an active expeller or other additional pusher rod to deploy the anchor. Rather, and because the anchor is carried solely on the external surface of the inserter, the anchor is deployed passively outside fibrous tissue upon retraction of the inserter. Further, the use of a disposable or single use inserter provided with a preassembled anchor can help reduce the time length of the procedure and simplify manipulations required during the procedure.

It will be further understood that the various embodiments of the inserters, anchors and coupling arrangements can be mixed and matched or combined in ways other than those explicitly discussed above, without departing from the scope of the present teachings.

The foregoing discussion discloses and describes merely exemplary arrangements of the present invention. One skilled in the art will readily recognize from such discussion, and from the accompanying drawings and claims, that various changes, modifications and variations can be made therein without departing from the spirit and scope of the invention as defined in the following claims. 

What is claimed is:
 1. A method for repairing a meniscal tear in meniscal tissue, comprising: positioning a first inserter carrying a first anchor on a distal outer surface of the first inserter adjacent to the meniscal tear; passing a distal end of the first inserter through the meniscal tear and deploying the first anchor at a first location on an outer surface of the meniscal tissue, wherein said deploying the first anchor at the first location includes retracting the first inserter relative to the meniscal tissue; retracting the first inserter relative to a second inserter; positioning the second inserter carrying a second anchor on a distal outer surface of the second inserter adjacent to the meniscal tear; passing a distal end of the second inserter through the meniscal tear and deploying the second anchor at a second location on the outer surface of the meniscal tissue; and reducing the tear by tightening a flexible strand coupling the first and second anchors.
 2. The method of claim 1, wherein said carrying the first anchor on the distal outer surface of the first inserter includes the first anchor in a folded configuration on the distal outer surface of the first inserter.
 3. The method of claim 1, further comprising passing the distal end of the first inserter through a cannula.
 4. The method of claim 3, further comprising passing the distal end of the second inserter through the cannula.
 5. The method of claim 4, further comprising positioning a distal end of the cannula adjacent to the meniscal tear.
 6. The method of claim 1, further comprising using the flexible strand to rotate the first anchor on the outer surface of the meniscal tissue.
 7. The method of claim 6, further comprising using the flexible strand to rotate the second anchor on the outer surface of the meniscal tissue.
 8. The method of claim 1, wherein said retracting the first inserter relative to the second inserter includes the first inserter sliding substantially parallel to the second inserter inside a cannula in which both the first inserter and the second inserter are positioned.
 9. The method of claim 1, further comprising passing the first anchor through the meniscal tear in a first orientation and rotating the first anchor to a second orientation outside the meniscal tissue.
 10. The method of claim 9, further comprising passing the second anchor through the meniscal tear in a first orientation and rotating the second anchor to a second orientation outside the meniscal tissue.
 11. The method of claim 1, further comprising abutting a buttress of the first inserter against a corresponding surface of the first anchor.
 12. The method of claim 11, further comprising keying a surface of the first inserter to a corresponding surface of the first anchor.
 13. The method of claim 11, wherein said first inserter is a unitary one-piece inserter.
 14. The method of claim 11, wherein said carrying the first anchor on the distal outer surface of the first inserter includes the first anchor positioned proximal of the distal end of the first inserter, and wherein the buttress of the first inserter and the distal end of the first inserter are provided by a single shaft body.
 15. The method of claim 1, further comprising abutting a buttress of the second inserter against a corresponding surface of the second anchor.
 16. The method of claim 1, further comprising sliding the first inserter substantially parallel to the second inserter.
 17. The method of claim 1, wherein the first anchor is carried on the distal outer surface of the first inserter without the first inserter penetrating the first anchor.
 18. The method of claim 1, wherein passing the distal end of the first inserter through the meniscal tear further includes piercing the meniscal tissue with the distal end of the first inserter that is carrying the first anchor on an exterior of the first inserter.
 19. The method of claim 18, wherein the first anchor includes a first end and a second end, the first and second ends of the first anchor being proximal to the distal end of the first inserter, where the distal end of the first inserter forms a passage through the meniscal tissue to carry the first anchor.
 20. A method for repairing a meniscal tear in meniscal tissue comprising: positioning a distal end of a cannula adjacent to a first side of the meniscal tear at a first location; passing and positioning a distal portion of a first elongated shaft carrying a first anchor through the cannula to the first location; piercing the meniscus with a distal end of the distal portion of the first elongated shaft, where the first anchor is positioned proximal the distal end to carry the first anchor from the first side of the meniscal tear to a second side of the meniscal tear at a second location on an outer surface of the meniscal tissue; retracting the first elongated shaft to deploy the first anchor at the second location; positioning the distal end of the cannula adjacent to the first side of the meniscal tear at a third location; passing and positioning a distal portion of a second elongated shaft carrying a second anchor through the cannula to the third location; piercing the meniscal tissue with a distal end of the distal portion of the second elongated shaft, where the second anchor is proximal the distal end to carry the second anchor from the first side of the meniscal tear to the second side of the meniscal tear at a fourth location on an outer surface of the meniscal tissue; retracting the second elongated shaft to deploy the second anchor at the fourth location; and reducing the meniscal tear by tightening a flexible strand coupling the first and second anchors.
 21. The method of claim 20, further comprising passing the first anchor through the meniscal tear in a first orientation and rotating the first anchor to a second orientation outside the meniscal tissue.
 22. The method of claim 20, further comprising passing the second anchor through the meniscal tear in a first orientation and rotating the second anchor to a second orientation outside the meniscal tissue.
 23. The method of claim 20, further comprising completely removing the first elongated shaft from the cannula after deploying the first anchor.
 24. The method of claim 20, further comprising sliding the first elongated shaft relative to the second elongated shaft.
 25. The method of claim 20, further comprising using the flexible strand to rotate the first and second anchors on the outer surface of the meniscal tissue.
 26. The method of claim 20, further comprising using a first buttress surface of the first elongated shaft to drive the first anchor through the meniscal tissue and utilizing a second buttress surface of the second elongated shaft to drive the second anchor through the meniscal tissue.
 27. The method of claim 26, wherein piercing the meniscal tissue with the distal end of the distal portion of the first elongated shaft includes piercing the meniscal tissue with a sharp edge of the distal end defined by a slanted surface.
 28. The method of claim 27, wherein the first anchor includes a first blunt end and a second blunt end and the first anchor is positioned on an exterior surface of the first elongated shaft where the first anchor is carried through the meniscal tissue as the sharp edge of the slanted surface of the distal end pierces the meniscal tissue and the first buttress drives the first anchor through the meniscal tissue.
 29. The method of claim 27, wherein the first anchor includes a first blunt end and a second blunt end and the first anchor is positioned on an exterior surface of the first elongated shaft, where the first anchor is carried through the meniscal tissue as the sharp edge of the slanted surface of the distal end pierces the meniscal tissue and the first buttress drives the first anchor through the meniscal tissue.
 30. The method of claim 20, wherein reducing the tear further comprises sliding a slip knot of the flexible strand to reduce the tear.
 31. A method for repairing a meniscal tear in meniscal tissue comprising: positioning a distal end of a cannula adjacent to a first side of the meniscal tear at a first location; passing and positioning a distal portion of a first elongated shaft carrying a first anchor through the cannula to the first location; piercing the meniscal tissue with a sharp edge of a distal end of the distal portion of the first elongated shaft defined by a slanted surface, where the first anchor is positioned proximal the distal end to carry the first anchor from the first side of the meniscal tear to a second side of the meniscal tear at a second location on an outer surface of the meniscal tissue by driving the first anchor through the meniscal tissue using a first buttress surface of the first elongated shaft that engages the first anchor; retracting the first elongated shaft to deploy the first anchor at the second location; positioning the distal end of the cannula to the first side of the meniscal tear at a third location; passing and positioning a distal portion of a second elongated shaft carrying a second anchor through the cannula to the third location; piercing the meniscal tissue with a sharp edge of a distal end of the distal portion of the second elongated shaft defined by a slanted surface, where the second anchor is positioned proximal the distal end to carry the second anchor from the first side of the meniscal tear to the second side of the meniscal tear at a fourth location on an outer surface of the meniscal tissue by driving the second anchor through the meniscal tissue using a second buttress surface of the second elongated shaft that engages the second anchor; retracting the second elongated shaft to deploy the second anchor at the fourth location; and reducing the meniscal tear by tightening a flexible strand coupling the first and second anchors.
 32. The method of claim 31, further comprising passing the first anchor through the meniscal tear in a first orientation and rotating the first anchor to a second orientation outside the meniscal tissue.
 33. The method of claim 31, further comprising completely removing the first elongated shaft from the cannula after deploying the first anchor.
 34. The method of claim 31, further comprising sliding the first elongated shaft relative to the second elongated shaft.
 35. The method of claim 31, wherein reducing the tear further comprises sliding a slip knot of the flexible strand to reduce the tear. 